Patient Smokes, Check. Now What?

Here's what: be prepared to provide an onslaught of relentless intervention

A colleague of mine, a few years older than me (he gave me permission to tell the story, although I'm not sure he'd like to be characterized as "older"), recently told me about an episode of shingles he suffered a few weeks ago.

Terribly painful, it had left some scarring along his torso, and now he was suffering from some moderate postherpetic neuralgia pain. Hurts to wear a shirt. He said he was "kicking himself" that he had never gotten the shingles vaccine.

Hearing the story, it made me think that somewhere in his medical chart was a notation from his primary care provider that says "shingles vaccine was recommended, patient declined, aware of risks."

Or else, if his electronic health record is set up this way, under the health maintenance tab under age/disease specific recommended vaccines, possibly the provider had gone to the trouble of clicking the "declined" button next to shingles.

All well and good, safely documented, a firm ground on which to stand.

This got me to thinking about quality, how we measure it in healthcare, and how our reports on how we're doing are being collected.

Are we going about this the right way?

If all the boxes are checked, and all our notes are full of patient counseling on the best clinical course we recommend, have we really provided the highest quality care to our patients?

Or have we just massaged the charts to make sure that we get a good grade?

Our institution is currently undergoing a huge investment of time and resources to try to standardize quality measurements and reporting across all the practices, and we are recognizing what a significant challenge this is.

For example, every patient who arrives at our practice is asked if they smoke, and if they do a box is checked.

There's another check box to show if counseling was offered, and a place to fill in how much they smoke, documentation of how much they smoke each day and for how many years.

We are planning to use natural language processing to read the Assessment and Plan section of our notes, to see whether the words "tobacco," "smoking," or "cessation," are included, as these would be markers that patient was appropriately counseled. (Unless we wrote that the patient was doing a smoking-good job of taking their medications.)

Since we already ask everybody who gets here whether they smoke, unless they refuse to answer, which is certainly their right, we know we're going to be pretty near 100% in terms of screening for tobacco use disorders.

And none of the providers here, if you asked them, would ever suggest that letting a smoker pass through our offices without at least trying to get them to quit would be a good idea.

But I'm pretty sure that all this asking and clicking is unlikely to significantly move, or be able to move in the future, the needle on how many of our patients still smoke, how many of them are trying to quit, and how made of them have made that jump to nonsmokers.

After all, there's a label on the side of the box of cigarettes that says smoking these things will kill you, and still people in this country continue to smoke.

I really think that a combined approach, a patient-centered approach, to getting to quality care is more likely to make a difference and improve on the things we are not doing so well on.

Certainly, the public health measures that we've taken to address smoking in our society have made an enormous impact, but when it comes down to the time of an office visit, primary care providers are almost always overwhelmed by the waves of issues coming at us while we try to care for patients to get to everything. Even something as important as smoking cessation.

We have tried something new to help us get real traction on this issue.

In our practice, anyone listed as a smoker (based on those buttons that are clicked or the presence of "tobacco use disorder" on their problem list) is flagged by the electronic health record, and a report is generated daily which is sent to our smoking cessation team.

The care coordinator on this team reaches out to every one of those patients as they arrive in the practice, and offers them a dedicated smoking cessation appointment.

They meet with one of our highly trained nurse practitioners, who has dedicated much of her life and energy to getting patients to quit smoking.

She meets with them individually, counsels them, harasses them with phone calls, offers them medication, and gets them to join group support meetings.

She is relentless.

The success rate she and her team have is significantly higher than any of us acting on our own, much better than clicking a box, and better than us gently (or not so gently) suggesting that our patients quit, offering them meds, and writing in our notes "smoking cessation strongly encouraged, patient says they are not ready to quit but will consider at a future date, aware of risks, benefits, alternatives."

This kind of an onslaught of intervention is what it will take to get our patients to quit smoking, to get their mammograms done, to take their medicines, to exercise, to continue their care beyond those brief moments we have with them in the office.

Only with the efforts of a truly patient-centered team will we actually improve the quality of the care our patients receive, and hopefully no one will end up "kicking themselves" that they didn't quit smoking, start taking their medicines, get that test done, take that vaccine.

Then we will move to a quality healthcare system with fewer smokers, healthier patients, and more vaccinated elderly physicians.

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